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Based on record review, interview and policy review, the facility failed to ensure staff reported monitoring alarms to the proper staff and failed to ensure patients were turned and repositioned to prevent the development of pressure ulcers. The hospital census was 536.

Based on record review, interview and policy review, the facility failed to ensure staff reported monitoring alarms to the proper staff and failed to ensure patients were turned and repositioned to prevent the development of pressure ulcers. This affected one (Patient #1) of 20 records reviewed.

Findings include:

1a. Review of the medical record of Patient #1 revealed the patient presented to the hospital as a transfer from an outside hospital on 01/25/25 at 11:24 PM. The patient was initially admitted to the outside hospital for syncopal episodes suspected to be cardiac in nature. According to the attending physician's history and physical, the patient had two cardiac arrests and was status post placement of permanent pacemaker on 01/21/25. On the afternoon of 01/25/25, the patient had another cardiac arrest with a downtime of nine minutes. Neurology evaluated the patient at the outside hospital due to concerns for a seizure prior to the code as the nurse noted lip smacking prior to the arrest. The patient's wife also reported staring spells at home. It was recommended that the patient be transferred to the facility's Medical Intensive Care Unit (MICU) for continuous video electroencephalogram (cvEEG) and further evaluation. On admission to MICU, the patient was a full code.

On arrival to MICU, the patient seemed to stir to voices, although requiring mechanical ventilation. The cvEEG Report revealed the continuous EEG began on 01/26/25 at 12:42 AM and ended on 01/26/25 at 11:41 AM. The report interpretation revealed there were no seizures seen over the entire monitoring period.

A note composed by a pulmonology physician on 01/26/25 at 10:00 PM stated the patient had worsening hemodynamic instability with increasing oxygen requirements. A chest x-ray was obtained that revealed a large right pneumothorax with tension. A chest tube to waterseal was placed by a fellow under direct supervision and assistance. A post procedure chest x-ray showed resolution of the pneumothorax and chest tube in correct position. Oxygen requirements improved. A direct cardioversion (a procedure that uses a controlled electric shock to reset the heart's electrical system and return it to a normal rhythm) was performed on 01/27/25. The patient was in normal sinus rhythm after the cardioversion. On 01/28/29, the patient was extubated and the decision was made to transfer the patient to a Cardiology Step Down Unit.

Patient #1 was transferred on 01/29/25 at 5:35 PM. An attending physician ordered continuous remote cardiac monitoring by the Cardiac Monitoring Unit. A physician also ordered to be notified if the patient's oxygen saturation was below 90 percent. At 6:29 PM, the patient's oxygen saturation was 90 percent and at 8:12 PM, 94 percent. A nurse's note at 11:01 PM stated the pulse oximeter was off at that time. The medical record lacked documentation the monitor watcher notified the nurse caring for the patient.

Review of the alarm messages for room #6346, the patient's room, revealed at 7:38 PM, the patient's oxygen saturation was less than 88 percent at 86 percent for 193 seconds, at 10:39 PM, the patient's oxygen saturation was less than 88 percent at 85 percent for 96 seconds, and for 38 seconds, the oxygen saturation was less than 88 percent at 87 percent. The medical record lacked documentation the monitor watcher notified the nurse caring for the patient.

At 11:13 PM, the patient care timeline revealed a patient care assistant arrived in the patient's room and found the patient unresponsive. The patient was extremely hypotensive with blood pressures of 50/20's. A nurse's note at 11:13 PM stated she was immediately notified and arrived to the room at 11:13 PM. The patient reportedly stopped moving and went pulseless. Chest compressions began. A code blue was initiated at 11:15 PM and the patient was intubated. Epinephrine 1 mg was administered at 11:18 PM. The patient was transferred back to MICU.

The facility policy titled Caring for the Patient on CMU (Remote Telemetry Monitoring), effective 12/30/24, was reviewed on 05/06/25 at 12:00 PM. According to the policy, upon initiation of CMU order for the patient, the nurse will call CMU and confirm the patient's room number, name, date of birth, code status, medical record number, telemetry box number, reason for monitoring, implantable devices, parameters as defined in the provider order, arrhythmia history, and nurse's name. Staff nurses are instructed of indications of Priority 2 or urgent alarms. Among other indications, the list included oxygen saturation out of parameter range for greater than thirty seconds. The policy advised the nurse to immediately call the registered nurse caring for the patient. The registered nurses are also advised that priority 3 or non-critical alarms include indications such as pulse oximeter being off or malfunctioning. For non-critical alarms, the registered nurses are also instructed to call the registered nurse's phone to inform the registered nurse caring for the patient.

Review of the CMU Shift Change Report Sheet from 01/29/25 revealed there was no communication to the nurse providing care to the patient. Staff FF was interviewed on 05/06/25 at 3:30 PM. These facts were confirmed.

Staff EE and Staff FF were interviewed on 05/06/25 at 3:30 PM and confirmed the monitor watcher was not notified when the patient's oxygen saturations dropped.

The facility policy titled "Caring for the Patient on CMU (Remote Telemetry Monitoring), effective 12/30/24, stated upon initiation of CMU order for the patient, the nurse will call CMU and confirm the patient's room number, name, date of birth, code status, medical record number, telemetry box number, reason for monitoring, implantable devices, parameters as defined in the provider order, arrhythmia history, and nurse's name. Staff nurses are instructed of indications of Priority 2 or urgent alarms. Among other indications, the list included oxygen saturation out of parameter range for greater than thirty seconds. The policy advised the nurse to immediately call the registered nurse caring for the patient. The registered nurses are also advised that priority 3 or non-critical alarms include indications such as pulse oximeter being off or malfunctioning. For non-critical alarms, the registered nurses are also instructed to call the registered nurse's phone to inform the registered nurse caring for the patient.

1b. Although the skin assessment and pressure injury risk assessment, completed by a MICU staff nurse on 01/26/25, revealed Patient #1 received a Braden score of 11, a high risk for breakdown, there was no indication that the patient had any wounds. A registered nurse's plan of care on 01/26/25 at 9:50 AM acknowledged the patient was at risk for skin breakdown due to his impaired mobility, however, the plan revealed the patient would be turned every two hours to relieve pressure.

Review of the flow sheet containing patient repositioning every two hours revealed that from 01/25/25 through 02/07/25, the patient was repositioned every two hours as he was restrained with bilateral soft wrist restraints and restraint checks every two hours included position change every two hours. The restraints were discontinued on 02/07/25.

On 02/08/25 at 12:00 PM, the patient was repositioned to a supine position. He remained in the supine position until 8:00 PM when he was repositioned to his right side at this time.

On 02/11/25 at 5:30 AM, the patient was repositioned to a supine position. He remained in this supine position until 11:00 AM when he was repositioned to his left side.

A wound care nurse's note on 02/12/25 at 3:59 PM stated the patient had a partial thickness wound to his sacrum.

On 02/14/25 documentation revealed the patient was reposition to a semi-Fowler's position at 4:00 AM. He was not repositioned again until 8:00 AM and he was still positioned to a semi-fowler's. He remained in this position until 4:00 PM, but repositioned again to semi-Fowler's.

There was no documentation his position was changed again until 02/15/25 at 8:00 AM on 02/15/25. He was repositioned to his right side at this time. The next documentation of repositioning was at 7:54 PM. He was again repositioned to his right side at this time.

The next documentation of reposition was on 02/16/25 at 8:30 AM. At 8:00 PM, the patient was repositioned to his left side. There was no documentation the patient was repositioned again until 02/17/25 at 8:00 AM.

A wound care nurse's note on 02/20/25 at 4:04 PM stated the patient now had a full thickness wound on his sacrum.

On 02/22/25 at 6:00 AM, 8:00 AM, 10:00 AM, and 12:00 PM the patient was repositioned to a semi-fowler's position. A wound nurse's note on 02/27/25 stated the sacral wound was moisture associated skin damage with erosion to sacrum that was an unstageable pressure injury.

On 03/03/25 at 8:00 AM, 10:00 AM, 12:00 PM, 2:00 PM, 6:00 PM, and 8:00 PM, the patient was repositioned to a semi-fowler's position. On 03/03/25 at 10:00 PM, the patient was repositioned to his right side.

There was no documentation the patient was repositioned again until 03/04/25 at 8:00 AM. At 8:00 PM, the patient was repositioned to a semi-fowler's position.

There was no documentation the patient was repositioned again until 03/05/25 at 8:00 AM. He was repositioned to his right side at this time.

A wound nurse's assessment on 03/06/25 at 9:15 AM documented an unstageable pressure ulcer to the patient's coccyx measuring 10 centimeters (cm) by 8 cm by 0.1 cm. On 03/10/25 at 12:00 AM, 4:00 AM, and 8:00 AM, the patient was repositioned to a semi-fowler's position. On 03/10/25 at 10:00 AM, the patient was repositioned to his right side. There was no documentation the patient was repositioned again until 6:00 PM. The patient was repositioned to a semi-fowler's position at this time. At 8:00 PM the patient was also repositioned to a semi-fowler's position.

There was no documentation the patient was repositioned again until 03/11/25 at 4:00 AM. He was repositioned to a semi-fowler's position at 9:00 AM.

A wound nurse's assessment on 03/11/25 revealed the unstageable pressure ulcer was now 12.5 cm x 13 cm x 0.3 cm.

An assessment by a wound nurse on 03/20/25 revealed the wound was now 13.5 cm x 10 cm x 2 cm. The coccyx wound was last measured on 03/27/25. The measurements were 13.5 cm x 11.2 cm x 3.1 cm. The patient was transferred to a long term acute care hospital on 04/03/25.

During an interview on 05/07/25 at 11:45 AM, Staff A verified the patient was not turned and repositioned every two hours.

The facility policy titled "Skin Care Prevention and Treatment", effective 06/01/19, instructed staff to turn and reposition patients every two hours.

Based on record review, interview and policy review, the facility failed to ensure a patient was provided community resources when they could not afford their medication. This affected one (Patient #3) of 20 medical records reviewed.

Findings include:

Review of the medical record of Patient #3 revealed the patient presented to the emergency department (ED) on 01/22/25 at 7:25 PM with complaints of a swollen and painful hand. She reported waking up on Sunday with pain and swelling of her hand. The patient also informed staff that she had gone to an urgent care but they advised her to go to the ED because her blood pressure was elevated. The patient stated she had a history of high blood pressure and ran out of medication about a month ago. At 7:32 PM, the patient's blood pressure was elevated at 189/110.

The Emergency Medicine Physician's history of present illness stated the patient reported that she had not been taking her blood pressure medication for at least four months due to financial constraints. The note further stated that the patient reported shortness of breath when lying down at nighttime. The patient stated she was supposed to have a sleep study, however, she did not have the time or money to get that done.

In the ED Course, the Emergency Medicine Physician's noted that the patient's blood pressure was likely elevated because she hadn't taken her medication. He stated he wasn't acutely treating the patient's blood pressure because she was otherwise asymptomatic. The physician phoned-in three refills of the patient's blood pressure medication. The patient was discharged home.

The medical record lacked documentation any community resources were provided upon discharge to assist Patient #3 with obtaining blood pressure medication.

The patient presented to the ED again on 02/26/25 at 2:24 PM with complaints of a sore throat. The patient reported that she had been around sick people. At 2:28 PM, the patient's blood pressure was 219/131. At 3:56 PM, the patient's blood pressure remained extremely elevated at 260/135. At 4:23 PM, the patient was medicated with Toradol 15 mg intramuscularly as the patient rated her throat pain a 10 on a 0-10 scale. At 4:24 PM, the patient's blood pressure was 191/117.

An ED physician's history and physical stated the patient reported not picking up the medications from the prescriptions that were phoned-in due to the expense.

The patient denied chest pain, headache, or lower extremity swelling. The patient was tested for Influenza A and B, Covid-19, Strep A, and RSV. All tests were negative and the patient was discharged home. Review of the discharge instructions revealed the patient was instructed to pick up three blood pressure medications that were again phoned-in to a pharmacy.

The medical record lacked documentation any community resources were provided upon discharge to assist Patient #3 with obtaining blood pressure medication.

The patient presented to the ED a third time on 03/02/25 at 9:18 AM with complaints of left eye pain. At 9:28 AM, the patient's blood pressure was 189/150. According to the Medication Administration Record (MAR), the patient was medicated with tetracaine HCL 0.5% ophthalmic solution two drops in both eyes. The decision was made to admit the patient to complete MRI imaging with neurology planning to see the patient the next day.

The patient was admitted to the facility Short Stay Unit where MRI imaging was performed, a CT scan was performed, and the patient was treated for severe hypertension.

During an interview on 05/01/25 at 2:00 PM. Staff P stated two social workers are available in the ED on a 24/7 basis. They are available to provide assistance for patients being discharged from the ED including financial assistance for discharge medications.

Review of the facility policy titled "Discharge Planning" stated the discharge process begins upon admission. An evaluation is conducted by physicians to determine the patient's care needs upon discharge. Staff is instructed that the discharge plan must include the determination of discharge medications and referral for appropriate community resources.